Crisis Protocols: Cochise County

Crisis Protocols: Cochise County 2016-2017 Final: 12/9/2016 Page 1 of 24 FINAL January 17, 2017

Table of Contents Involved Parties... 4 Overview & Purpose... 4 Goals of the Crisis System... 5 Definitions... 5 Meeting Attendance... 9 The Cochise County Crisis System Meeting... 10 Crisis Mobile Team (CMT) / NurseWise Meeting... 10 Procedures to Identify and Address Joint Training Needs... 10 Problem Resolution Process... 10 Continuity of Covered Services During a Crisis... 10 Crisis During Business Hours... 11 Notes on Medical Clearance... 11 Crisis Services... 12 What is Considered a Crisis?... 12 Law Enforcement and the Crisis System... 12 The NurseWise Crisis Line (NW)... 12 Crisis Mobile Team (CMT)... 12 Intake and Coordination of Care Agencies (ICC Agencies)... 12 My Health Direct Appointments (MHD)... 13 Warm Line... 13 Tribal Warm Line... 13 Teen Lifeline... 13 Critical Incident Stress Management (CISM)... 13 Drug and/or Alcohol Use... 14 Services Available for Substance Use... 14 Community Bridges Inc. (CBI)...14 How to Refer to CBI...14 Transfers of Care...14 Crisis Mobile Team Response in the Community... 15 Services Available... 15 Page 2 of 24 FINAL January 17, 2017

Crisis Mobile Team Response to Group Homes and Residential Facilities... 15 Services Available to Private Psychiatrists (in office)/persons at a Local Psychiatrist s Office... 16 Crisis Mobile Team Services at an Inpatient Psychiatric Facility... 16 Crisis Services at Fort Huachuca, US Army Post... 16 Involuntary Persons in Need of Mental Health Treatment... 16 A Person in a Cochise County Emergency Department or in the Community... 17 Steps to Petition:... 17 A Person in the Community... 18 A Person at an ICC Agency During Business Hours... 19 Involuntary Treatment of Service Men/Women at Fort Huachuca, US Army Post... 19 During Business Hours... 19 After Hours... 19 When Law Enforcement are Involved... 20 Jail Diversion and Safety... 20 Voluntary Crisis Services for Detained Persons... 20 At the Cochise County Jail... 21 At a Juvenile Detention Center... 21 Non-Emergent Requests for Involuntary Evaluation (PAD or GD)... 22 Direct Admission to a Behavioral Health Inpatient Facility (Acute or Sub-Acute)... 22 By Outpatient Providers (Voluntary Only)... 22 By Crisis Mobile Teams (Voluntary Only)... 22 By Another Hospital (ED or Medical Floors)... 22 Coordination of Care with Local Hospitals... 23 Medically Admitted Patients Enrolled in an Open Episode of Care at Any Hospital... 23 Signature Pages... 25 Page 3 of 24 FINAL January 17, 2017

Involved Parties Arizona Counseling & Treatment Services (ACTS) Arizona s Children Association (AZCA) Benson Hospital Benson Police Department Bisbee Police Department Canyon Vista Medical Center Cenpatico Integrated Care Cochise County Attorney s Office Cochise County Sheriff s Office Community Bridges Inc. (CBI) Community Health Associates (CHA) Copper Queen Community Hospital Corazon Douglas Police Department Easter Seals- Blake Foundation Huachuca City Police Department Northern Cochise Community Hospital NurseWise (NW) Pinal Hispanic Council (PHC) Raymond W. Bliss Army Health Center Sierra Vista Police Department Southeastern Arizona Behavioral Health Services (SEABHS) Southern Arizona Veterans Health Care System Tombstone Marshal s Office US Army Garrison Fort Huachuca Willcox Police Department Overview & Purpose The Protocols are guidelines that describe how we will all work together to ensure that behavioral health services are delivered in Cochise County. The Purpose is to enhance the network and response capability to address behavioral health crisis in Cochise County through ongoing communication and collaborative agreements between community system partners and behavioral health provider agencies developing an environment where there is no wrong door. Cenpatico Integrated Care (herein referred to as Cenpatico) and their contracted providers and identified Cochise County Community system partners agree to coordinate activities to facilitate the implementation of crisis services in Cochise County. The elements of the Crisis System (including referral, assessment and service implementation processes) and the roles and responsibilities of each agency are outlined below. Cenpatico and their contracted providers and identified Cochise County Community system partners agree to work in partnership on behalf of persons experiencing a behavioral health crisis to ensure they receive the appropriate services and level of care that promote resiliency and healthy communities. Page 4 of 24 FINAL January 17, 2017

These guidelines will be active from date of signature until modified by the involved parties. These guidelines do not create or delegate obligations or financial responsibilities. These guidelines are not a legal and binding contract or Memorandum of Understanding. These guidelines should never override the obligation to provide the most clinically appropriate intervention based on each individual situation nor should they override law or professional responsibility to members. Agencies are encouraged to have adequate clinical supervision and guidance to support such actions. Goals of the Crisis System To ensure persons receive the appropriate services and level of care, stabilize persons in the community whenever possible, support individuals in their recovery, promotes resiliency and healthy communities. Definitions Active Episode of Care: Means a person has been opened with and are receiving services at a contracted RBHA funded agency. The person may have any of the following eligibility and entitlements: Title 19 (AHCCCS or SSI/MAO) Title 21 (KidsCare) Seriously Mentally Ill (SMI) only Medicare and SMI Medicare, SMI and Title 19 NOTE: Cenpatico is the physical health plan for persons designated with a Seriously Mentally Ill (SMI) enrolled as Title XIX. Persons who are Dual Eligible, meaning they have both Medicare and Title 19 coverage, and enrolled in General Mental Health (GMH) or Substance Abuse (SA) services now receive all medically necessary physical and mental health services under acute care AHCCCS Plans. Cenpatico remains the crisis provider for all populations regardless of health plan assignment. Admitting Officer Per ARS 36-501: Means a psychiatrist or other physician or psychiatric and mental health nurse practitioner with experience in performing psychiatric examinations who has been designated as an admitting officer of the evaluation agency by the person in charge of the evaluation agency. Application for Emergency Admission (Form MH-104): Paperwork completed to initiate a request for evaluation of a person who, based on reasonable cause, is in such a condition that without immediate hospitalization he or she is in eminent danger and likely to harm himself/herself or others. Application for Evaluation (Form MH 100): Paperwork completed to initiate a request for an evaluation of a person who is alleged to be Persistently or Acutely Disabled (PAD) and/or Gravely Disabled (GD) and may also be alleged to be Danger to Self (DTS) and/or Danger to Others (DTO). This form is required for both emergent and non-emergent requests for evaluation. Page 5 of 26 FINAL January 17, 2017

Behavioral Health Inpatient Facility- (Formerly Referred to as Level I Inpatient, Level 1 Sub Acute, or RTC): A facility licensed per 9 A.A.C. 20 and includes a psychiatric acute hospital (including a psychiatric unit in a general hospital), a residential treatment center for persons under the age of 21, or a sub-acute facility. For the purposes of these protocols, a Behavioral Health Inpatient Facility does not include residential treatment. Business Hours: Monday through Friday from 8am to 5pm. Brief Intervention Program (BIP): Brief Intervention Programs (BIP) are a facility based crisis service that are an alternative to level one. They are designed to provide short term crisis intervention for adults and children who need additional 24/7 support but do not require placement in a behavioral health inpatient facility. They are available for crisis placements 24/7. Community Observation Center (COC): Community Observation Centers provide facility based crisis intervention services to a person for the purpose of stabilizing or preventing a sudden, unanticipated, or potentially dangerous behavioral health condition, episode, or behavior. These intensive and time limited services are designed to prevent, reduce, or eliminate a crisis situation and are provided 24 hours a day, 7 days a week. Community Stabilization: Community Stabilization is the overall goal of the crisis system. The Community Stabilization philosophy of care encourages crisis intervention in the community versus removing a person from the community to address a crisis. Cenpatico considers a person community stabilized if after an initial crisis mobile team encounter, there is no inpatient hospitalization for a period of 45 days after this encounter. Crisis: An acute, unanticipated, or potentially dangerous behavioral health condition, episode or behavior. Crisis Intervention Services (Mobile, Community Based): Crisis intervention services provided by a mobile team or individual who travels to the place where the person is experiencing the crisis (e.g., person s place of residence, emergency room, jail, community setting) to: Stabilize acute psychiatric or behavioral symptoms Evaluate treatment needs Develop plans to meet the needs of the persons served Depending on the situation, the person may be transported to a more appropriate facility for further care (e.g., a crisis services center). Crisis Intervention Services (Telephone): Crisis intervention (telephone) services provided by qualified service providers within the scope of their practice to triage, refer and provide telephonebased support to persons in crisis. This is often the first place of access to the behavioral health system. This service may also include a follow-up call to ensure the person is stabilized. Page 6 of 26 FINAL January 17, 2017

Danger to Self (DTS): (a) Behavior which, as a result of a mental disorder, constitutes a danger of inflicting serious physical harm upon oneself, including attempted suicide or the serious threat thereof, if the threat is such that, when considered in the light of its context and in light of the individual's previous acts, it is substantially supportive of an expectation that the threat will be carried out. (b) Behavior which, as a result of a mental disorder, will, without hospitalization, results in serious physical harm or serious illness to the person, except that this definition shall not include behavior that establishes only the condition of gravely disabled. Danger to Others (DTO): The judgment of a person who has a mental disorder is so impaired that he is unable to understand his need for treatment and as a result of his mental disorder his continued behavior can reasonably be expected, on the basis of competent medical opinion, to result in serious physical harm to others. Evaluation Agency Per ARS 36-501 (13): A health care agency that is licensed by the department and that has been approved pursuant to this title, providing those services required of such agency by this chapter. Gravely Disabled (GD): A condition evidenced by behavior in which a person, as a result of a mental disorder, is likely to come to serious physical harm or serious illness because he/she is unable to provide for his/her basic physical needs. Guardian: A guardian is a person who has the legal authority to make personal decisions for the ward relating to living arrangements, education, social activities, and authorization or withholding of medical or other professional care, treatment, or advice. The guardian must always make decisions that are in the best interests of the ward. Intake and Coordination of Care Agency (ICC Agency): (Also referred to as Outpatient Treatment Agencies or Provider Agencies). ICC Agencies are a contracted provider type requiring full execution of Intake Provider functions and requirements. ICC Agencies must accept all requests for services for eligible populations and are required to manage members care by performing the following roles: intake, assessment, service planning, clinical oversight of all services, service tracking and data reporting, enrollment and demographic submissions, education, engagement activities, psychiatric services and ensure adequate treatment service availability to all enrolled members. ICC Agencies are further divided into High Needs Recovery Center (HNRC) and Low to Moderate Needs Recovery Centers (LMNRC). ICC Agencies are required to screen members and refer them to either an HNRC or an LMNRC. Mental Health Authorization to Transport This is a document pursuant to ARS 36-525-A that states a peace officer shall on the advice of the admitting officer of the evaluation agency pursuant to section 36-524, subsection E apprehend and transport a person to an evaluation agency. Natural Supports: Refers collectively to support commonly identified as: a. "Informal Support " (support provided by those individuals who know or are related to the individual/family, but do not provide a paid service, such as a grandparent or neighbor who is connected to the individual/family). Page 7 of 26 FINAL January 17, 2017

b. "Community Support" (those supports that are part of the individuals/family's community, such as faith community, neighborhood or community organizations). Persistently and Acutely Disabled (PAD): A severe mental disorder that meets all the following criteria: a. If not treated has a substantial probability of causing the person to suffer or continue to suffer severe and abnormal mental, emotional or physical harm that significantly impairs judgment, reason, behavior or capacity to recognize reality. b. Substantially impairs the person's capacity to make an informed decision regarding treatment and this impairment causes the person to be incapable of understanding and expressing an understanding of the advantages and disadvantages of accepting treatment and understanding and expressing an understanding of the alternatives to the particular treatment offered after the advantages, disadvantages and alternatives are explained to that person. c. Has a reasonable prospect of being treatable by outpatient, inpatient or combined inpatient and outpatient treatment. Petition: A mental health petition is the paperwork that must be completed and filed with the court in order to place a person under court ordered evaluation. The prescribed forms can be found in the Arizona Administrative Code. (R9-21-501) Crisis Mobile Teams all have access to the proper forms. Revocation of the Outpatient Treatment Portion of a Court Order: The process outlined in ARS 36-540-(E) subsection 4 or 5 in which the medical director of the mental health treatment agency can request the court order a person court ordered to outpatient treatment back into inpatient treatment. Seriously Mentally Ill (SMI): A condition of persons who are eighteen years of age or older and who, as a result of a mental disorder as defined in A.R.S. 36-501, exhibit emotional or behavioral functioning which is so impaired as to interfere substantially with their capacity to remain in the community without supportive treatment or services of a long -term or indefinite duration. In these persons mental disability is severe and persistent, resulting in a long-term limitation of their functional capacities for primary activities of daily living such as interpersonal relationships, homemaking, selfcare, employment and recreation. SMI is a designation (eligibility category) that comes with an insurance benefit package under the RBHA. Social Detox: Social detox refers to short term crisis services provided to persons experiencing withdrawal from substances and that withdrawal does not require the patient to be medically supervised. Community Bridges is able to provide this level of service in Casa Grande and in several locations around Southern Arizona. Second Responder: Cenpatico has developed several Second Responder Teams that are able to work with persons who have been in a recent crisis. Referrals can be made by the Crisis Mobile Team, NurseWise or a Community Observation Center. Services are time limited (from 2 weeks to 45 days maximum). In Cochise County the Second Responder Service available is the Peer Crisis Aftercare Services. Page 8 of 26 FINAL January 17, 2017

Specialty Provider: A provider type that delivers specialized programs and treatment services in treatment facilities, the community, member homes or specified offices to meet the unique needs of special populations. Required service hours, locations, populations served and special treatment programs are outlined in their contract with Cenpatico. Title 36: Arizona s state law for mental health commitments. The law is located in the Arizona Revised Statutes, Title 36 (Public Health and Safety) Chapter Five (Mental Health Services). Title 36 Pre-Petition Screening: The review of an application (MH 100) requesting court-ordered evaluation, including an investigation of facts alleged in such application, an interview with each applicant, and an interview, if possible, with the proposed patient. The purpose of the interview with the proposed patient is to assess the problem, explain the application and, when indicated, attempt to persuade the proposed patient to receive, on a voluntary basis", evaluation or other services. In Cochise County pre-petition screenings are conducted by Horizon Health and Wellness or Crisis Preparation and Recovery (CPR). This is to be done only when the Application for Emergency Admission (MH 104) is not completed. Warm Line Transfer: A warm line transfer is when a phone call to the crisis line is transferred to another party and the crisis line professional stays on the call while the call is introduced to and accepted by the intended recipient before the call is transferred. WRAP Plan: Wellness Recovery Action Plan-is a self-management and recovery system developed by a group of people who had mental health difficulties and who were struggling to incorporate wellness tools and strategies into their lives. WRAP plans are developed by the consumer. The plan helps people to monitor uncomfortable and distressing symptoms and identify ways to help reduce, modify or eliminate those symptoms by following plan strategies. The plan includes an outline of who can help and how they can help as well as preferred management strategies and treatments. Wrap Services: Also referred to as wrap around services; these are supportive services provided to a person at home or in the community designed to provide additional support to a person in crisis or to prevent a crisis. Planned services are available 24/7/365. Wrap services include an array of professional, community, and natural (i.e., family, friends) supports and are individualized based on the needs of the person and the family. Meeting Attendance The strength of the crisis system is in part dependent upon the level of participation of involved system partners, the RBHA and local agencies. Successful meetings will also require a focus on systems issues. Specific complaints about individual situations should be handled as outlined in the Problem Resolution Process. All parties agree to have representation at meetings and agree to participate actively in the process. Page 9 of 26 FINAL January 17, 2017

The Cochise County Crisis System Meeting This quarterly meeting has been established to identify areas in which there is a need for procedures or improved communication between the behavioral health system, law enforcement, emergency departments, the County Attorney s Office, and local providers. Attendance is encouraged since this meeting is a primary means for system partners, the RBHA and RBHA contracted agencies to discuss and examine the current procedures to address and intervene during a behavioral health crisis. The group represents a collaborative effort to identify barriers and strengths in the crisis system and to develop agreements and processes to build on strengths and resolve barriers. Crisis Mobile Team (CMT) / NurseWise Meeting Cenpatico holds meetings regularly to follow up with Crisis Mobile Team providers and NurseWise staff on how the crisis system is working. Procedures to Identify and Address Joint Training Needs Cenpatico is committed to working collaboratively with local system partners to identify trainings that will be needed as well as trainings that will be continued. Trainings that are available may include but are not limited to AZPOST trainings, Crisis System Overview, CIT Programming, Crisis Intervention and Stress Management Debriefing (CISM) training and Mental Health First Aid (MHFA). Problem Resolution Process Conflicts between specific agencies or regarding specific situations are handled between the agencies involved. Cenpatico is always willing to assist in this process if called upon to do so. It is agreed that problem resolution is best completed in real time by following the chain of command. It is agreed upon that for effective problem solving, system issues that present a problem will be discussed in the Cochise County Crisis System Meeting. The Cenpatico First Responder Liaison is also a resource for Cochise County when concerns arise. The Liaison can help resolve problems related to specific situations as they relate to the crisis system and can also help file official complaints with Cenpatico Customer Service if necessary. Continuity of Covered Services During a Crisis Cenpatico has a business continuity plan to ensure continuity of operations and services in the event of a crisis or disaster. Cenpatico will be working with local emergency and disaster preparedness entities to ensure Cenpatico is included into the County s response plans. Separate protocols and agreements will be developed outside of the crisis system protocols. Page 10 of 26 FINAL January 17, 2017

Crisis During Business Hours During regular business hours outpatient service providers will provide crisis intervention to enrolled members who are in a crisis and in the presence of their treatment provider. Crisis intervention services include assessment, de-escalation techniques and crisis counseling as well as crisis and follow up planning by a recovery coach (case manager), clinician, behavioral health professional, or prescriber. In some situations crisis intervention may include need for an evaluation for a medication change by a prescriber followed by close monitoring by the clinical team. Other options may be intervention involving wrap around services to the person in the community such as accessing the person s support system, activating the person s WRAP plan and or advance directive, seeking respite services, or coordinating wrap services with a HNRC, Specialist agency and or primary ICC Agency. Per AHCCCS contractual requirements, ICC Agencies should always strive to place a person in the least restrictive environment. For crisis, this may mean a referral to a facility based crisis service. Facility based crisis services include Brief Intervention Programs (BIP), Social Detox, and Community Observation Centers. If there are no other safe alternatives, placement in a psychiatric facility may be needed on an emergency basis. In these situations, the prescriber can do a direct admission to a receiving psychiatric facility. If hospitalization is needed, the prescriber must have knowledge of and be able to attest to the need for an inpatient admission. Recovery Coaches and other direct service staff will conduct bed searches and make arrangements for admission. The prescriber will be required to complete a doc-to-doc phone call to the admitting agency. In these situations, there is no need to send the member out for medical clearance unless the receiving facility (or sending prescriber) has a symptom generated concern that must be evaluated medically. If medical clearance is requested the outpatient team must find out the reason for the request and document this in the clinical record. In some cases, unnecessary medical clearance may be avoided if recent health assessment documentation can be provided to the receiving facility or a doc to doc can help rule out medical concerns. Outpatient providers will ensure there is sufficient staff coverage including protocols outlining the chain of command when a member is in crisis and in need of immediate intervention. In addition, contractual agreements between Cenpatico and intake providers require all contracted agencies have urgent and emergency appointments available to ensure that enrolled members can be seen at the agency when an emergency arises. Notes on Medical Clearance It should not be assumed that medical clearance is needed for every admission. There may be exceptions and alternatives to taking a person to the Emergency Department. Medical clearance is not required unless the receiving facility (or sending prescriber) has a symptom generated concern that must be evaluated medically. Page 11 of 26 FINAL January 17, 2017

Crisis Services What is Considered a Crisis? A crisis is measured by the person experiencing it. If the situation exceeds the person s coping skills, then the person is in crisis. Can the crisis system take calls for people diagnosed with a developmental disability, Alzheimer s or Dementia? Yes. There are no medical conditions that exclude a person from receiving crisis services. The crisis line and or crisis team can assess, intervene and make recommendations for any person in crisis. It is important to note that in order for the person to be admitted to a psychiatric facility under his or her insurance, he or she must have a treatable psychiatric condition and be accepted by the admitting physician at that facility. Law Enforcement and the Crisis System All First Responder calls are treated as priority and quickly triaged so the crisis can be addressed immediately. Similarly, CMTs are dispatched with priority for all law enforcement requests for crisis services and CMT resources are concentrated in high volume call areas. The NurseWise Crisis Line (NW) The NurseWise Crisis Line is available 24 hours a day, 7 days per week by calling 866-495-6735. If a Crisis Mobile Team (CMT) is needed the request must be made to NurseWise who will triage and dispatch CMTs. NW will check enrollment status for every call. Crisis Mobile Team (CMT) Mobile team providers in Cochise County include Community Bridges Inc. (CBI) and CHA. CHA covers Douglas and Bisbee, and CBI covers Benson, Willcox and Sierra Vista. Crisis Mobile Team assessment and intervention services are available to any person in the County regardless of insurance or enrollment status. CMT response times are 60 minutes in town and 90 minutes outside of town. CMT requests from First Responders are prioritized and response times are 30 minutes in town and 60 minutes outside of town. Per AHCCCS contractual requirements, CMTs should always strive to place a person in the least restrictive environment. For crisis, this may mean a referral to a facility based crisis service. Facility based crisis services include Brief Intervention Programs (BIP), Social Detox, and Community Observation Centers. If there are no other safe alternatives, placement in a psychiatric facility may be needed on an emergency basis Intake and Coordination of Care Agencies (ICC Agencies) ICC Agencies are available to members for intensive wrap (supportive) services providing the necessary supports to avoid crisis and/or out of home placement and can conduct crisis assessment, brief intervention and treatment for members at their facility who are in crisis. High Need Recovery Centers are also available after hours as needed. ICC Agencies are notified during business hours of a crisis in real time by the CMT and every effort is made to coordinate with the member s clinical team on an appropriate plan for the member in crisis. Both the NW Crisis Line and Crisis Mobile Teams are required to coordinate care with the ICC Agency when an assigned member is in crisis. Page 12 of 26 FINAL January 17, 2017

My Health Direct Appointments (MHD) MyHealthDirect offers a platform that interfaces with all Cenpatico contracted provider s schedules so emergency and after hours follow up and intake appointments can be completed. This often becomes part of a safety and follow up plan for a person who was in a crisis. NW schedules these appointments after a recommendation by the CMT or a Community Observation Center. Warm Line The Warm Line is a confidential, non-emergency phone line for any resident of a Cenpatico covered County who needs to talk. The service offers Peer Support operators who have first-hand experience living with mental illness or substance use either through personal experience, or the experience of a close family member. The number is 520-770-9909. The hours of operation for the warm line are 8am-12am daily. Tribal Warm Line The Tribal Warm Line (TWL) is a Cenpatico peer support service, run by NurseWise (Cenpatico s crisis line provider). The TWL provides no cost over-the-phone support to American Indian community members and is staffed by Tribal Support Partners (TSPs) who are tribal members living in their own communities. The number is 855-728-8630. Teen Lifeline Teen Lifeline is a free and confidential 24/7 crisis hotline for youth in Arizona. Between the hours of 3pm and 9pm, trained peer counselors are available to speak with youth and teenagers about any problems or crisis they are facing. Teen Lifeline's crisis hotline is available by call or text at 602-248- 8336 (call or text) or 800-248-8336 (call only). Critical Incident Stress Management (CISM) An intervention protocol developed specifically for dealing with traumatic events. It is a formal, highly structured and professionally recognized process for helping those involved in a critical incident to share their experiences, vent emotions, learn about stress reactions and symptoms and given referral for further help if required. Crisis Mobile Teams can be accessed to complete CISMs in the community following a traumatic event. The service is accessed by calling NurseWise. Page 13 of 26 FINAL January 17, 2017

Drug and/or Alcohol Use Per ADHS Practice Protocol Co-occurring Psychiatric and Substance Disorders, Assessment begins at the point of clinical contact, regardless of the client s clinical presentation. Initiation of assessment should not be made conditional on arbitrary criteria such as length of abstinence, non-intoxicated alcohol level, negative drug screen, absence of psychiatric medication, and so on. Thus, a person under the influence who self identifies as being in crisis is eligible for the array of crisis services offered by the RBHA. There is no requirement for the person to reach a certain level of sobriety before being assessed. The only requirement is that the person must be able to physically participate in an interview. The Title 36 statute does not preclude a person under the influence of substances from being petitioned for involuntary treatment. The statute does require that there be evidence of a mental disorder as defined in ARS 36-501.25. Services Available for Substance Use Community Bridges Inc. (CBI) CBI has several Substance Abuse Transitional Facility drug and alcohol treatment facilities. This facility accepts any adult who has used alcohol or other addictive substances (opiates, barbiturates, tranquilizers and stimulants) within the previous 7 days or a benzodiazepine with the last thirty days. A person can stay at CBI for up to 5 days based on clinical need. They have a no wrong door policy and they take drop offs and walk-ins. They also have outpatient substance use services and can get people enrolled for long term services if this is desired. How to Refer to CBI CBI is available 24 hours per day, 7 days per week to take referrals. (Benson: 520-586-6171; Globe 928-425-2415; Payson 928-468-0022; Casa Grande 520-426-0088) CBI can also pick up members upon request. o Law enforcement can bring persons to CBI o A CMT can bring a person in o A recovery coach can bring a person in o A member can self-refer Transfers of Care As a result of the no wrong door philosophy, once assessed, persons in crisis may need to be transferred from one facility to another in order to receive the most appropriate treatment. The person is not medically compromised The person is voluntary for treatment The primary concern is drugs and or alcohol The person is currently under the influence of a substance or has used substances in the last 7 days Page 14 of 26 FINAL January 17, 2017

NOTE: CBI employs Emergency Medical Technicians (EMTs) who can conduct a basic medical screening to identify any potential acute medical concerns. If medical care is needed, an ambulance will be requested to transport the person to the nearest ED. Crisis Mobile Team Response in the Community Services Available A Crisis Mobile Team is available to all persons in the community to assist them in overcoming a crisis situation, assessing the need for an out-of-home placement, and coordinating safety planning. Crisis Mobile Teams are committed to responding to the community including but not limited to places such as the home, school, church, the streets, and jails. There is no need to bring a person in crisis to the Emergency Room unless there is a medical emergency. NOTE: CMTs are required to have vehicles to facilitate transportation and field interventions as well as cell phones for communications. Crisis Mobile Teams & Transportation Requirements for Voluntary Persons Experiencing a Crisis If a person is seen by a CMT and a higher level of care is needed, CMTs are to assess and identify whether a transport can be provided in a safe manner by the following (in this order): 1. Natural supports 2. The ICC Agency 3. The Facility receiving the person 4. The CMT 5. Local Emergency Services Each situation where a person is in crisis must be evaluated from a clinical perspective and should be treated individually. Crisis Mobile Team Response to Group Homes and Residential Facilities Group home staff are expected to be trained in crisis intervention and are expected to provide crisis intervention services as needed. During regular business hours the ICC Agency should be contacted for facilitation of care and discussions surrounding inpatient treatment. After hours the Crisis Mobile Team can respond to assist with crisis assessment and coordination of follow up services. In the case the member is enrolled with a high needs recovery center, the placement should identify if there is a plan for after-hours crisis intervention and follow the plan accordingly. Page 15 of 26 FINAL January 17, 2017

Services Available to Private Psychiatrists (in office)/persons at a Local Psychiatrist s Office A crisis mobile team can be requested by a local psychiatrist by calling NurseWise (1-866-495-6735). The CMT will provide assessment, crisis intervention and recommendations for further treatment (if applicable). A CMT is not able to facilitate an inpatient admission for a person with private insurance under the care of a private psychiatrist. In these situations, the private psychiatrist would be responsible for facilitating an inpatient admission by coordinating with the person s insurance carrier and/or facilitating a direct admission to a psychiatric facility. NOTE: This does not prevent a CMT from completing a T36 pre-petition screening at a private psychiatrist s office. Crisis Mobile Team Services at an Inpatient Psychiatric Facility CMTs will not respond to an inpatient psychiatric facility. The only exception would be if the facility is requesting a T36. Crisis Services at Fort Huachuca, US Army Post Fort Huachuca permits the CMT to respond within the premises of Fort Huachuca when contacted by a provider at Raymond W. Bliss during normal duty hours. If NurseWise is contacted about a person in crisis on post and the person is not an imminent danger to self/others, then arrangements can be made for the CMT to meet the person away from Fort Huachuca. In this case, it is not necessary to send the person to the local ER since the CMT can travel near the post and assess the person in the community. If NurseWise is contacted about a person in crisis on post and the person poses an immediate risk, then Military Police must be notified at (520) 533-3000. Cenpatico has a separate agreement with Fort Huachuca that outlines how services are received. Involuntary Persons in Need of Mental Health Treatment Per ARS 36-545.06 Each county shall provide directly or by contract the services of a screening agency and an evaluation agency for the purposes of this chapter [Title 36 Chapter 5]. In Cochise County the Crisis Mobile Teams (CMT) will conduct pre-petition screenings on behalf of the County. Screenings can also be completed by an ICC Agency for members in the presence of their treatment provider who may require involuntary treatment. Pre-petition screening services are not a RBHA covered service. The Crisis Mobile Teams are accessed through NurseWise, the 24 hour crisis line for the County (866-495-6735). Page 16 of 26 FINAL January 17, 2017

A Person in a Cochise County Emergency Department or in the Community If a person in the community/ed is in need of mental health treatment but not voluntary, NurseWise will be contacted at 1-866-495-6735 and a Crisis Mobile Team (CMT) will be requested. The CMT will meet with the person where they are and attempt to engage the person in treatment voluntarily. If the CMT is unable to do so, and the person is dangerous to self or others (if PAD or GD please refer to Non-Emergency Requests for Involuntary Evaluation) the CMT will need to evaluate for involuntary treatment and begin the screening process to refer the person to an evaluation facility for a Title 36 screening as follows: The CMT will ensure that the Application for Emergency Admission for Evaluation (Form A3), witness statements and a behavioral health assessment are completed and available for review. Steps to Petition: It is preferred that the screening agency fill out the Application (form A3), the Applicant Statement (form A2B) and at least two Witness Statements. If the petitionable behavior was not observed by the agency, form MH 105 should be filled out by the agency and approved by the Medical Director. The screening agency must ensure that witnesses are aware that they will be required to testify in court. The applicant cannot fill out a witness statement. 1. The screening agency will complete the petition packet which includes the following: a. Form A01 Request to Initiate b. Form A02 information sheet c. Form A2 Application for Involuntary Evaluation (must be signed and notarized) OR d. Form A 3 Application for Emergency Admission for Evaluation (must be signed and notarized) AND e. Form A2b Applicant statement re: COE f. Form A5-Pre-petition screening report. Note: the attempt to complete the screening must still be documented and filed with the original petition paperwork even if it is unable to be completed. g. Form A6.1 Petition for Evaluation signed by the medical director IF the applicant did not observe the petitionable behavior h. Form A1.1 Two Witness statements - Emergency or A1.2 Non Emergent i. Form A9.1 Authorization for apprehension and transport signed by the screening agency medical director or the evaluation agency s admitting officer only when there is an allegation of dangerousness 2. The screening agency will fax the paperwork to the receiving evaluation agency for review. 3. The admitting officer of the evaluation agency will decide if the person meets criteria to be admitted for an evaluation and either accept or deny the patient. If the evaluation agency does not have a bed, the screening agency will continue searching for an accepting evaluation facility.. NOTE: The need for medical clearance will be determined on a case by case basis. The mobile team or agency should coordinate with the admitting officer of the evaluation agency to identify the need for such clearance. Page 17 of 26 FINAL January 17, 2017

4. Once the bed is secured, the screening agency/cmt will facilitate transportation to the evaluating agency. Per ARS 36-525, when there is an allegation of dangerousness, a peace officer shall, upon the advice of the admitting officer (the psychiatrist, medical doctor or mental health nurse practitioner at the evaluation agency) apprehend and transport the person to an evaluation agency. Transportation will be facilitated as follows: a. The CMT staff will call local law enforcement and advise them they need a peace officer transport for a T36 emergency evaluation. b. Law enforcement will arrive on scene and transport the person to the evaluation agency. 5. The CMT will ensure that the original petition paperwork is filed with the County Attorney s Office within 24 business hours of the admission. The paperwork should be scanned and emailed to the following parties: Kaguilar@cochise.az.gov ; eorduno@cochise.az.gov ; sblanchard@cochise.az.gov cbarney@cochise.az.gov; lowen@cochise.az.gov. 6. The agency or Crisis Mobile Team must advise the witnesses that they must be available to testify at a hearing. The County Attorney s Office will notify potential witnesses at their earliest convenience by sending a subpoena if appropriate. If the Application for Emergency Admission (MH 104) is Declined An Application for Emergency Admission can only be declined after a review by the admitting officer (psychiatrist or Nurse Practitioner). If this occurs, there must be a safety plan developed for the person by the CMT. The CMT will follow up with LE if they were involved in the original call. If the Person is Found to be Petitionable on a Non-Emergent Basis (PAD and/or GD) A non-emergent petition is completed by an agency contracted with the County as a screening and evaluation agency. If the member is enrolled in an active episode of care, it is recommended that the clinical team be consulted and that they work with the CMT/Screening Agency to facilitate the process including gathering witnesses and information. The CMT/screening agency can assist in filling out or fill out the application and will complete a screening. The CMT/screening agency will file the application. If the CMT/screening agency is not able meet with the person face to face, a screening report can still be completed and an application filed. A Person in the Community If a person in the community is in need of mental health treatment but is not voluntary, NurseWise will be contacted and a Crisis Mobile Team (CMT) will be sent. The CMT will meet with the person where they are and attempt to engage the person in treatment voluntarily. If the CMT is unable to do so, and the person is dangerous to self or danger to others, the CMT will facilitate an emergency petition for involuntary treatment by following the steps outlined in the Section entitled Involuntary Persons in Need of Mental Health Treatment and the Special Questions outlined above. Page 18 of 26 FINAL January 17, 2017

A Person at an ICC Agency During Business Hours During regular business hours service providers will provide crisis intervention to enrolled members who are in a crisis and in the presence of their treatment provider. The clinical team should provide services as outlined in section entitled Crisis During Business Hours. If the team is unable to engage the person in treatment, and the person is danger to self or others, the team will need to call NW and request a CMT/screening agency for a Title 36 screening. 1) The outpatient team staff member will call NW and give a verbal summary of the presenting issues, results of the assessment, and any other pertinent information needed for a Title 36 2) This information will also be used for subsequent discharge planning. Refer to Steps to Petition. Involuntary Treatment of Service Men/Women at Fort Huachuca, US Army Post During Business Hours (7:30am-3:30pm) Active duty persons in crisis are received by the Raymond W. Bliss Army Health Center behavioral health unit (BHU). If the person is a danger to self/others and needs hospitalization, the treatment professionals at the BHU will coordinate admission and treatment. Civilian family members in crisis are received by the BHU. If the civilian admission is on a voluntary basis, then the treatment professionals at the BHU will coordinate admission and treatment. If the civilian admission is on an involuntary basis, then treatment professionals will arrange transportation to Canyon Vista Medical Center. After Hours (3:30pm-7:30am) Ft. Huachuca s medical center closes at 3:30pm and reopens at 7:30am. Per Fort Huachuca internal protocol, active duty service members AND civilian family members in crisis are transported by natural supports (family, friends, etc) or ambulance to the Canyon Vista Medical Center. Page 19 of 26 FINAL January 17, 2017

When Law Enforcement are Involved If law enforcement encounters a person who appears to be in a psychiatric crisis and who refuses voluntary psychiatric evaluation, per ARS 36-525, a peace officer may take into custody any individual the peace officer has probable cause to believe is, as a result of mental disorder, a danger to self or others, and that during the time necessary to complete the prepetition screening procedures set forth in sections 36-520 and 36-521 the person is likely without immediate hospitalization to suffer serious physical harm or serious illness or to inflict serious physical harm on another person If the peace officer determines this to be the situation, the peace officer can request that the person be screened for an emergent involuntary petition by calling NurseWise. The person that observed the petitionable behavior will need to fill out the paperwork to initiate an Application for Emergency Admission (MH 104). The CMT/screening agency will be available to assist law enforcement and/or the applicant as needed in determining the standard by which the person will need to be petitioned as well as the proper forms to complete. The CMT/screening agency will follow the Steps to Petition above. Jail Diversion and Safety The goal of the crisis system is to intervene quickly in a crisis and stabilize the person in the least restrictive setting possible. The Crisis Line and the Crisis Mobile Teams are an alternative to calling 911 for community members. The CMT develops a crisis and safety plan for community members who are deemed safe to remain in the community after a crisis and both CMTs and the Crisis Line follow up with the member after a crisis. Additional diversion options if law enforcement are called would include facility based crisis services that are available when a person is in need of an additional level of support. The Cenpatico crisis system partners with law enforcement to ensure diversion at the patrol level utilizing training on crisis system usage, real-time intervention, and systemic problem solving to improve safety and collaboratively identify additional diversion processes. Agreements, protocols and Memorandums of Understanding may be developed with the County Jail to further define collaborative efforts to divert persons in need of mental health and substance use away from the jails. Voluntary Crisis Services for Detained Persons NOTE: Contractual agreements between Cenpatico and local intake provider agencies require all said agencies to coordinate care of enrolled members with jails and detention centers. Coordination of care can be achieved by visiting the person or participating in treatment and release planning for enrolled members. Page 20 of 26 FINAL January 17, 2017

At the Cochise County Jail If a person in the jail appears to be in a psychiatric crisis (danger to self or others, persistently or acutely disabled or gravely disabled) jail staff can call NurseWise and request a Crisis Mobile Team (CMT). The CMT will provide crisis assessment and short term crisis intervention as well as the following: 1. Determine if the inmate meets criteria for filing a Title 36; and 2. Whether or not the inmate agrees to undergo treatment; and 3. Coordinate with CAO regarding the inmate s charges and coordinate with the Civil Division of the County Attorney s office regarding the possibility of dismissal and/or modification of release conditions so that the inmate can be transported to a locked treatment facility for evaluation/treatment. The CMT can only provide its treatment recommendations to the jail. The CMT will contact the Civil Division of the County Attorney s Office regarding the need for treatment, the charges, if appropriate, and the Civil Division of County Attorney s Office will contact the assigned Prosecutor or the jurisdictional judge regarding dismissal and/or modification of release conditions. NOTE: The CMT cannot authorize the removal of a patient from the jail to facilitate further treatment. No inmate may be released, even to a locked facility, without an order from the court. If the Prosecutor agrees and the judge orders the patient released for further treatment; once a bed is found the Civil Division will prepare the Order for Transport and submit the order to the appropriate jail staff for transport of the patient to the treatment facility. Jail staff shall never be responsible for initiating a Title 36 petition. In the absence of an available Jail Liaison, jail staff will refer an inmate to the CMT for assessment, the CMT will perform the required assessments and will prepare all of the required Title 36 documents, with the exception of witness statements. Any jail staff who has witnessed the inmate s behaviors will be available to complete a Witness Statement. The Civil Division of the County Attorney s Office will notify any witness via Subpoena. At a Juvenile Detention Center If a juvenile in detention is in a psychiatric crisis the detention center can call NurseWise and request a Crisis Mobile Team (CMT). The CMT can provide crisis assessment and short term crisis intervention as well as recommendations to detention staff. The CMT can only make recommendations to the detention center and cannot remove the child from the facility to facilitate further treatment. If the CMT does recommend a higher level of care for a person in detention, the detention center will follow internal protocols to facilitate placement in an appropriate treatment setting. NurseWise will assist with locating an appropriate treatment setting by providing detention center staff, upon request, with bed availability information at receiving psychiatric hospitals. In this situation, if there is an outpatient clinical team, they should assist in locating placement. Page 21 of 26 FINAL January 17, 2017